Site Mobile Navigation

Obamacare Can't Win an All-In Wager

WASHINGTON — “Liberals have many tails,” the American writer and satirist H.L. Mencken observed, “and chase them all.”

The fate of the Obama health care initiative could rest in large part with some members of his party’s left wing, who threaten to let the perfect be the enemy of the good. Several dozen members of the House of Representatives, a few senators and the incoming head of the A.F.L.-C.I.O. labor organization have complained that without a government-run public option to counter private insurance, any effort to remake health care is meaningless. Other liberals have complained about too-generous concessions to the drug industry or doctors.

In the end, this is probably a bluff. If not, they will blow an opportunity that will take them years to recoup.

Their reasoning ignores both the history of major legislation and the specifics of this health-care effort. With few exceptions, sweeping initiatives in the U.S. system start small, are often flawed and are then expanded — sometimes improved, sometimes not.

“If you can’t get a whole loaf,” Joseph Califano, who was President Lyndon Johnson’s top domestic adviser when Medicare was enacted in 1965, said in an interview with Charlie Rose of PBS on Sept. 9, “take a half, take a third.”

Medicare, the system that provides government-funded health care to senior citizens, is a classic illustration. It was a huge achievement, culminating a decades-long battle, yet in many aspects it was minimalist.

Over the next decade, the measure was expanded to cover more people, conditions and services: those under 65 or with disabilities, as well as chiropractic treatment, and speech and physical therapy. Since then, coverage has grown to include hospice benefits, mammograms and Pap smears to detect cancer, and most recently, under the Republicans, prescription drugs.

The left-wing skeptics should also listen to the most capable liberal legislator in Congress, Representative Henry Waxman. In arguing for a watered-down climate change bill earlier this year, the California Democrat urged his colleagues to see that “the essential thing is to get something in place.”

He knows the history of environmental legislation. The 1970 Clean Air Act was a landmark measure, authorizing federal and state regulations to limit emissions. Some of the real muscle to clean up the polluted air, however, came with the 1977 and 1990 amendments to the original measure.

In the current battle, President Barack Obama, who lost ground in a summer of discontent, got back in the game with a deft address to Congress last week, inspiring much of his liberal base and appealing to skeptical centrists. He refuted myths that the Democrats might establish “death panels” to make end-of-life medical decisions or that illegal immigrants would be given federal health insurance.

In an age of 24/7 media hype, such absurdities won’t vanish. Last month, as a New York Democratic representative, Anthony Weiner, championed the federal Medicare program, a cable television anchor asked him: If it was so good, why wasn’t he on it? The 45-year-old explained he was 20 years away from qualifying.

Still, Mr. Obama’s speech provided cover for fence-sitters on the fringe stuff. His major objective now is to persuade moderate to conservative Democrats in the House and Senate — along with perhaps a handful of Republicans — to support the start of intense negotiations during the next two months over the shape of a final bill. The odds slightly favor success unless the liberals get out on a limb and pull the plug.

“I am not interested in passing health care reform in name only,” said Senator Russ Feingold, a Democrat from Wisconsin. “Without a public option I don’t see how we will bring real change.”

In the House, Maxine Waters, the left-wing lawmaker from Los Angeles, warned the president to stop negotiating with conservative Democrats and Republicans. “We know that you are a nice man that would want to work with the opposite side of the aisle. But there comes a time when you need to drop that and move forward,” she said.

The White House knows that to make these conditions the litmus test of health care overhaul is suicidal. The political reality is that a measure with a public option cannot command a majority in the Senate, perhaps not even in the House. Whatever the merits of a government-run option, it is not the determinative issue of a successful transformation of health care, according to the Congressional Budget Office, the White House and academic experts.

Any final bill likely would enact radical changes to health insurance industry practices — no longer could coverage be denied because of pre-existing conditions, or existing policies rescinded because of an illness, or contain annual or lifetime ceilings. It is also likely to provide coverage to 25 million to 30 million more Americans through health exchanges, and adopt some measures to slow huge increases in health care costs.

Would Mr. Feingold and Ms. Waters throw that away? “There will be some threats, but ultimately most liberals will go along,” predicts Representative Edward Markey of Massachusetts, a Democrat. “The danger is the more some say it’s an absolute precondition, the more difficult it is to get off that.”

If more persuasion is necessary, advocates should consider borrowing the words of the late liberal lion of the Senate, Edward Kennedy of Massachusetts. In his book “True Compass,” to be released posthumously Monday, he writes: “One of the great lessons I’ve learned from a life in politics is that no reform is ever truly complete. We must constantly keep moving forward.”

If the economy continues to slowly improve, Afghanistan doesn’t crater and Democrats pass a major health care overhaul, the party, in the next election, might well hold its own in the Senate and lose only 15 to 20 House seats.

If they fail on health care — déjà vu of 1994 — some of those Democrats won’t return to Washington; those who do may have to get used to calling Republican colleagues Mr. Chairman.